Provider Demographics
NPI:1760473730
Name:POURAT, MANOUCHEHR
Entity Type:Individual
Prefix:
First Name:MANOUCHEHR
Middle Name:
Last Name:POURAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 CREBS AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6819
Mailing Address - Country:US
Mailing Address - Phone:818-996-7341
Mailing Address - Fax:
Practice Address - Street 1:19307 SATICOY ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2330
Practice Address - Country:US
Practice Address - Phone:818-885-1825
Practice Address - Fax:818-885-8960
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH47607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist